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ORTHODONTIC INDICES
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
Definition:
 An index has been defined as a numerical value describing
the relative status of a population on a graduated...
Uses:
1)
Indices are used extensively in Northern
Europe in determining access to public health
orthodontics or the level ...
TYPES OF INDICES (W. C. Shaw AJO 1995)
There are five types of index, each for a distinct
purpose. Indeed it is the purpos...
II. Epidemiologic indices
These indices record every trait in a malocclusion to
allow estimation of the prevalence of
malo...
III. Treatment need (treatment priority) indices
Allow categorization of malocclusion according to the
level of treatment ...
IV Treatment outcome indices
Several indices have been developed to evaluate treatment
success.
PAR index described later ...
The methods of recording and measuring malocclusion can be broadly divided into
two types: qualitative and quantitative - ...
4 . Occlusal feature index of Poulton & Aaronson that records lr
antr crowding, cuspal inter-digitation, overjet and overb...
QUANTITATIVE METHODS OF MEASURING
MALOCCLUSION

In 1951 Massler and Frankel made the initial attempt to
develop a quantit...
Evolution of Indices:
About the year 1800, people started to think that
certain arrangements of the human teeth
constitute...


In 1938, Henry Klein developed the DMFT
(decayed, missing, filled) scale that was and is still
the ultimate in simplici...
Grainger developed the malocclusion severity
estimate (MSE), in the Burlington Research
Center. It can be used either on m...
The occlusal index (OI) was developed by Summers in 1966 and was
based on the malocclusion severity estimate, with attempt...
Grainger, in 1967, modified the MSE to develop the treatment priority
index (TPI). Grainger described the index as a metho...
In 1972, Harvey Peck and Sheldon Peck developed
a diagnostic index for assessing tooth shape
deviations was for spatial an...


The malocclusion index problem arises
because of the need to identify which
patient's treatments will be paid for with ...
The "WHO/FDI Basic Method for Recording of
Malocclusion" was published in 1979 to establish an
assessment format to determ...
In 1986, Cons, a Public Health dentist, is the only
American dentist to produce any kind of an index
since then. Cons appr...
In 1989, California was sued for failing to comply with the
orthodontic provisions of the Medicaid statutes. An orthodonti...
Grade Index Scale for assessment of treatment
need:

The Swedish National Board developed a four grade
index scale designe...
Espeland produced a new approach in
Norway for their mixture of public and
private funding of treatment to determine
the l...
In 1987, the British Orthodontic Standards Working
Party convened a series of meetings with a group
of 10 experienced Orth...
More recently in 1989, Brook and Shaw (EJO) developed the
index of orthodontic treatment need (IOTN), which
consisted of t...
The requirements for an index of occlusion have been summarized
in a World Health Organization report in 1979








A symptom may either be constant (present at all ages)
or variable (fluctuating with age).
An index must con...
INDICES
DRAKES – HANDICAPPING LABIOLINGUAL
DEVIATION (HLD) INDEX
1.
Cleft palate – All or none
2.
Traumatic deviation – Al...
California modification of Handicapping labiolingual
deviation index
To assess the presence or absence and degree of handi...
6
7
8

Overbite in mm
Mandibular protrusion in mm x 5
Open bite in mm – No occlusal contact in
anterior x 4
9 Ectopic erup...
Summary of the rules: (William S. Parker -1998 Aug)
1. Study models must be diagnostic. [This means that they
must be prop...
2. All measurements are judged on the basis of
greater than or more than the minimal criteria
considering only the erupted...
6. Ectopic eruption
i.
the eruption of the first molar resorption
of distal root of the primary second molar
ii. transpose...
vii.Regarding mutually blocked out teeth, only one will be
counted.






The most difficult issue is the use of the w...
Demerits:
Carlos and Ast tested the ability of the HLDI in
distinguishing "handicapping" and "nonhandicapping"
malocclusio...


MALOCCLUSION SEVERITY ESTIMATE –
GRAINGER (1960-61)

Measurements:
1)
Overjet
2)
Over bite
3)
Anterior open bite
4)
Con...
Six malocclusion syndromes defined:
i. Positive overjet, anterior open bite
ii. Positive overjet, posterior over bite, dis...
Summer's Occlusal Index 1966.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Molar relation
Overbite
Overjet
Posterior cross bite
Posterior o...
Seven Syndromes:
1.
2.
3.
4.
5.
6.
7.

Overjet & open bite
Distal molar relation, Overjet, Overbite, Posterior
crossbite, ...
TPI – GRAINGER 1967
(11 Weighted measurements)
1)
Upper anterior segment overjet
2)
Lower anterior segment overjet
3)
Over...
Seven malocclusion defined:
1) Maxillary expansion syndrome
2) Over bite
3) Retrognathism
4) Open bite
5) Prognathism
6) M...
Grainger described the index as a method of assessing the
severity of the most common types of malocclusion, and
hence, pr...
Merits:
A few manifestations of malocclusion, such as midline diastema
and slight asymmetry, were rejected as being of lit...
Demerits:

It is inadequate for assessing the occlusion of the
deciduous or mixed dentition.

As there is no "mixed dent...


SALZMANN INDEX (1968)
 Handicapping malocclusion assessment records
1. Intra arch deviation – missing teeth, crowding,...


Salzmann's purpose of developing the HMAR was to provide a means
for establishing priority for treatment of handicappin...
A Peck and Peck index for assessing tooth shape
deviations (1972 Apr AJO)

Odontometry is the science of measuring the siz...
Mesiodistal width of mandibular incisor
Index = ----------------------------------------------------- x 100
Faciolingual w...
Applications:
1. Prediction of unerupted tooth size similar to mixeddentition analyses by Moyer's and
Nance
2. Assessment ...
WHO or FDI CLASSIFICATION – 1979:
1. Gross anomalies
2. Dentition – missing, supernumerary, malformed
incisor, ectopic eru...
DENTAL AESTHETICS INDEX (DAI)
Regression coefficient
Scoring descriptions
Actual weight

Rounded wt

5.76

6

1.
Number of...
IOTN Dental health component
Grade 1 – None – Variations < =1mm
Grade 2 – Little
1)
Overjet >3.5mm <6 mm with competent li...
Grade 3: Moderate
1) Overjet >3.5mm <6mm with
incompetent lips
2) Reverse overjet >1mm <3.5mm
3) Increased overbite or com...
Grade 4: Great
1)
Overjet 6-9mm
2)
Reverse overjet >3.5mm with no functional
difficulties
3)
Overbite with gingival trauma...
Grade 5: Very great
1) Defects of cleft lip or palate
2 Overjet >9mm
3 Reverse overjet >3.5mm – mastication and
speech dif...
AESTHETIC COMPONENT OF IOTN
I Children form:
Orthodontic concern:
1.
I am satisfied with the way my teeth come
together 1-...
Global negative Self-Evaluation scale (GSE)
1.
At times I think I am no good at all
2.
I feel I do not have much to be pro...
II Parents form:
A. 1) I am satisfied with the way my child's teeth come
together.
2) I want to have my child's teeth stra...
Index of Orthodontic Treatment Need (IOTN) - W. C. Shaw AJO
1995
It ranks malocclusion in terms of the significance of var...
The Esthetic Component of IOTN.
The esthetic component consists of a 10-point scale, illustrated by a
series of numbered p...
1. Resource allocation and planning for limited public and
other third-party resources for orthodontic care, to direct
res...
Disadvantage:
Risk of insensitivity and misjudgment of the
needs of the individual patient.
None of the available systems ...
Peer Assessment Rating or PAR index Richmond 1987:
1)

A scoring system was developed and a ruler designed to
allow analys...


4
The PAR index and IOTN were applied to the
pretreatment and posttreatment casts. The mean percentage
reduction in PAR...
6

7

The investigation of treatment standards is a more challenging step for
the specialty.
Poor standards of orthodontic...
10.
1.
2.
3.
4.
5.

The measurements made are:
Overjet
Overbite
Midline relation
Buccal Occlusion
Upper anterior crowding
Ideal tooth relationship index - Haeger AJO May 1992
It is a static occlusal analysis in centric occlusion based on
ideal ...















Characteristic Features:
Index scores were generated for the entire dentition, which could be
div...
Results:
Evaluation of treated malocclusions
 Total ITRI score
1)
An initial of 26%
2)
Increased to 52% at the end of ort...








Buccal relationships in the posterior segment produced
higher scores than the lingual segment.
Lingual cusp r...


The system allowed the computation of a total index score
that could be divided into arch segments and components
of th...


OCCULUSAL FEATURES INDEX BY
POULTOND AARONSON – 1961
1. Lower anterior crowding
2. Cuspid interdigitation
3. Vertical o...
FISK INDEX 1960:
Dental age was used for grouping.
A – P: Angle's classification, overjet, anterior crossbite
Transverse: ...
BJORK, KREBS & SOLOW –1964
1. Dental anomalies, abnormal eruption,
malalignment
2. Occlusal anomalies – Deviations between...

1.
2.

3.
4.

5.

PROFITT AND ACKERMANN – 1973
Alignment – Ideal, crowding, spacing, mutilated
Profile – Mesiodistal pro...


EVALUATION OF MALOCCLUSION
INDICES



The reproducibility or reliability of an index is the ability
to produce the sam...


Bias, or systemic error of an index or
measurement is the magnitude and direction of its
tendency to measure something ...


Weights were first introduced to put different
emphasis on various measurements.
 Only the OI had developed different ...


Hermanson and Grewe tested the
precision and bias of five malocclusion
indices including the HMAR, the OI, the
TPI, and...


Grewe and Hagan compared the HMAR, the OI,
and the TPI for precision and bias when used in
the same population. The res...


Summers tested the validity of three
indices: The CHAMPUS index, the HMAR,
and the OI. The OI was found to be the
most ...


Gray and Demirjian compared the
reproducibility and accuracy of four indices: the
HLDI, the TPI, the OI, and the HMAR. ...


The TPI and the OI were very highly correlated and had
some common characteristics. Both needed very close and
careful ...
The HMAR correlates fairly well with the standard but not as
closely as the TPI or the OI. However, it had advantages as
w...
Yet it still has short comings. Elderton and Clark pointed out
that OI needs to be refined to allow scoring when first
per...



Conclusion:
A good method of recording or measuring malocclusion is
important for documentation of the prevalence and...
Thank you
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www.indiandentalacademy.com
Orthodontic indices /certified fixed orthodontic courses by Indian dental academy
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Orthodontic indices /certified fixed orthodontic courses by Indian dental academy

  1. 1. ORTHODONTIC INDICES INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  2. 2. Definition:  An index has been defined as a numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits, which is designed to permit and facilitate comparison with other populations classified by the same criteria and methods. – A.L.Russel.  An index is an expression of clinical observation in numerical values, which is used to describe the status of the individual or group with respect to a condition being measured. – E.M.Wilkins.  In the orthodontic context index is a method that assigns a numeric score or alphanumeric label in order to rate or categorize a person's occlusion.
  3. 3. Uses: 1) Indices are used extensively in Northern Europe in determining access to public health orthodontics or the level of third party copayment. 2) Have a role in resource allocation. 3) Planning and promoting treatment standards. 4) Identifying prospective patients. 5) Informed consent. 6) Assessment of the outcome of treatment. 7) In quality assurance and research.
  4. 4. TYPES OF INDICES (W. C. Shaw AJO 1995) There are five types of index, each for a distinct purpose. Indeed it is the purpose rather than content or conventions of an index that distinguishes it. I. Diagnostic classification Angle's classification with its subclasses used to describe incisor and buccal segment relationships separately allows ease of communication between orthodontists.
  5. 5. II. Epidemiologic indices These indices record every trait in a malocclusion to allow estimation of the prevalence of malocclusion in a given population. Other indices of this type score tooth alignment in a way that allows study of tooth irregularity and periodontal disease, or treatment stability Eg: Epidemiologic registration of malocclusion by Bjork, Krebs, and Solow The FDI method Summer's occlusal index.
  6. 6. III. Treatment need (treatment priority) indices Allow categorization of malocclusion according to the level of treatment need. These indices yield a score for each trait or component that is then weighted to calculate an overall score. A simpler method of assigning treatment priority is to establish a list of conditions or traits in categories that denote the extent to which treatment is considered necessary. Eg: i) Draker's HLD index. ii) Grainger's treatment priority index. iii) Salzman's handicapping malocclusion assessment. iv) IOTN.
  7. 7. IV Treatment outcome indices Several indices have been developed to evaluate treatment success. PAR index described later has been developed specifically for this purpose. Summer's index has also been used to assess the outcome of treatment. V. Treatment complexity index At present no index has been described to specifically measure treatment complexity but the desirability of such an index in public health orthodontics is recognized and efforts are presently underway to develop one.
  8. 8. The methods of recording and measuring malocclusion can be broadly divided into two types: qualitative and quantitative - Tang and Wei AJO Apr 1993 QUALITATIVE METHODS OF RECORDING MALOCCLUSION 1) Angle's method of classifying malocclusion in 1899 [But Case pointed out that Angle's method disregarded the relationship of the teeth to the face and although malocclusion was a three-dimensional problem, Angle's system had only taken into account anteroposterior deviations in the sagittal plane. When Gravely and Johnson tested reliability, Angle's system was unreliable, including difficulty associated with asymmetry between left and right sides, or where tooth movements had occurred because of factors such as crowding and premature loss of deciduous teeth.] 2) Massler & Franel's index recording the no. of displaced/rotated teeth in 1951. 3) Draker's HLD Index in 1960.
  9. 9. 4 . Occlusal feature index of Poulton & Aaronson that records lr antr crowding, cuspal inter-digitation, overjet and overbite. 5 . Malocclusion severity index by Grainger in 1961 6 . Summer's Occlusal index in 1966 7 . Treatment Priority Index by Grainger in 1967 8 . Salzmann HMAR in 1968.
  10. 10. QUANTITATIVE METHODS OF MEASURING MALOCCLUSION  In 1951 Massler and Frankel made the initial attempt to develop a quantitative method of assessing malocclusion. The total number of displaced or rotated teeth was the basis for the evaluation of prevalence and incidence of malocclusion in population groups.  In 1959, VanKirk and Pennell proposed the malignment index, which involved the grading of tooth displacement and rotation quantitatively.  Draker developed the handicapping labiolingual deviation index (HLDI) in 1960  Poulton and Aaronson proposed the occlusal feature index in 1961. Since only four features of occlusion were measured this index was considered incomplete
  11. 11. Evolution of Indices: About the year 1800, people started to think that certain arrangements of the human teeth constituted perfection. This “idea” in the minds of men was that this configuration was normal and hence “ideal” occlusion. Soon, the notion developed that what was not ideal was not normal and was therefore abnormal! In 1889, Edward H. Angle came on the scene and declared that the relationship of the first molars defined proper occlusion and stated that arrangements other than his definition were abnormal and by inference malocclusion.
  12. 12.  In 1938, Henry Klein developed the DMFT (decayed, missing, filled) scale that was and is still the ultimate in simplicity in measuring dental conditions for large numbers of people.  In 1960, H. L. Draker suggested a different approach in which selected deviations from ideal were scored and weighted. He called it the Handicapping Labio-lingual Deviation index or HLD Index.
  13. 13. Grainger developed the malocclusion severity estimate (MSE), in the Burlington Research Center. It can be used either on models or on patients. Validity and reproducibility were high. However, there were at least three possible shortcomings of the MSE, namely: (1) the index was derived from data of 12-year-old patients and therefore might not be valid for earlier stages of dental development in the deciduous and mixed dentitions; (2) the MSE score didn't reflect all measurements that were accumulated and (3) the absence of any occlusal disorder was not scored as zero.
  14. 14. The occlusal index (OI) was developed by Summers in 1966 and was based on the malocclusion severity estimate, with attempts to remedy its shortcomings.  The first shortcoming of the MSE could be remedied by scoring for each stage of dental development (i.e., deciduous, mixed, and permanent dentition stages) and different scoring forms were used for subjects in each stage.  The second shortcoming was remedied by considering the scores of all syndromes in arriving at the final OI score. The MSE considered only the score of the syndrome with the highest score, but in the OI, the other scores were also considered by adding half of the sum of the remaining scores to the highest score among the seven syndromes.  The third shortcoming was remedied by adjusting for normality, so that the absence of any occlusal disorder would be scored as zero.
  15. 15. Grainger, in 1967, modified the MSE to develop the treatment priority index (TPI). Grainger described the index as a method of assessing the severity of the most common types of malocclusion, and hence, provided a means of ranking patients according to the severity of malocclusion, the degree of handicap, or their priority of treatment In 1968, Salzmann developed the handicapping malocclusion assessment record (HMAR). The assessment forms and the definition of handicapping malocclusion presented were officially approved by the Council on Dental Health of the American Dental Association, and the Board of Directors of the American Association of Orthodontists Others who worked on this included Massler and Frankel, VanKirk and Pennell, Bjork et al, Summers, Freer and Adkin, Ingervall and Ronnerman, and Helm.
  16. 16. In 1972, Harvey Peck and Sheldon Peck developed a diagnostic index for assessing tooth shape deviations was for spatial analysis of existing or potential malocclusions. In 1976, The Champus program, the Armed Forces of the United States contracted with the National Research Council to organize a work force to define “seriously handicapping orthodontic conditions” An excellent committee of highly qualified workers in the field labored for some time but was unable to produce such a definition.
  17. 17.  The malocclusion index problem arises because of the need to identify which patient's treatments will be paid for with tax dollars. Both the civilian (Medicaid) and military (Champus) programs in the United States require that ”need“ be demonstrated. Need is defined as ”medically necessary handicapping malocclusion“ in Medicaid parlance.
  18. 18. The "WHO/FDI Basic Method for Recording of Malocclusion" was published in 1979 to establish an assessment format to determine the prevalence of malocclusion and to estimate treatment needs of a population. In 1985, the AAO formally recalled that action and specifically declared that they were opposed to the use of any index of malocclusion to identify patients needing treatment. Since that declaration, no American orthodontist has produced any work on these indexes.
  19. 19. In 1986, Cons, a Public Health dentist, is the only American dentist to produce any kind of an index since then. Cons approached the index problem from purely the appearance standpoint and developed the Dental Aesthetic Index. They generally used the opinions of the lay public as to what constituted unacceptable dental arrangements from the aesthetic standpoint. The Dental Aesthetic Index has been accepted by the World Health Organization as a screening tool. The Medicaid statutes, as described in The State Medicaid Manual in April 1988, direct each state to provide orthodontic treatment for medically necessary handicapping malocclusion.
  20. 20. In 1989, California was sued for failing to comply with the orthodontic provisions of the Medicaid statutes. An orthodontist was offered a contract for 20 hrs to draft a narrowly defined criteria and guidelines for determining medically necessary orthodontic treatment. He used the HLD Index but intended to add the 3 missed-out features viz., deep impinging bites traumatizing the soft tissue of the palate, crossbites of individual anterior teeth destroying the soft tissue and a large maxillary protrusion with reasonably aligned teeth - buck tooth which is an extreme social handicap. It also included ectopic eruption suggested by Draker. Hence the HLD (CalMod) Index came into being. In 1994, California was sued again and led to some needed changes in the regulations. Overjet greater than 9 mm and reverse overjet greater than 3.5 mm were inserted as a qualifying exception.
  21. 21. Grade Index Scale for assessment of treatment need: The Swedish National Board developed a four grade index scale designed to determine whether a patient's malocclusion, to classify patients ranging from those who need very urgent orthodontic treatment to those of little need to identify who fall within the scope of treatment in the Swedish public dental services. However, the criteria were not well defined and the cut off points were vague.
  22. 22. Espeland produced a new approach in Norway for their mixture of public and private funding of treatment to determine the level of public health copayment that the patient may be entitled to, i.e., total reimbursement for severe malocclusion with cleft lip and palate, and partial or nil reimbursement for malocclusions considered minor.
  23. 23. In 1987, the British Orthodontic Standards Working Party convened a series of meetings with a group of 10 experienced Orthodontists to develop an index of treatment outcome from study casts of various treated and untreated occlusions. Richmond designed a ruler to allow analysis of a set of study casts in 2 minutes (approx). The result was the Peer Assessment Rating or PAR index.
  24. 24. More recently in 1989, Brook and Shaw (EJO) developed the index of orthodontic treatment need (IOTN), which consisted of the dental health component and the esthetic component. In the dental health component, occlusal traits thought to contribute to the longevity and satisfactory functioning of the dentition were defined and placed in five grades, with clear cut-off points. The esthetic component consisted of a 10-point scale illustrated by a series of numbered photographs that were rated for attractiveness. The index was found to be satisfactorily valid and reproducible. In 1992, Haeger also developed a static occlusal analysis in centric occlusion based on ideal interarch and intraarch relationships and called it ideal tooth relationship index.
  25. 25. The requirements for an index of occlusion have been summarized in a World Health Organization report in 1979
  26. 26.       A symptom may either be constant (present at all ages) or variable (fluctuating with age). An index must concentrate on, and be sensitive to the basic orthodontic defect, and must not be unduly sensitive to the symptom. During time, the index score for the occlusal disorder should either remain constant or increase during time, indicating that the occlusal disorder is the same or getting worse. Validity is the ability of an index to measure that which it purports to measure Reproducibility is the ability to reproduce the original ratings or scores when the same or different examiner reexamines the subject. The index should be easy to learn, ideally allowing rapid recording of relevant features by both trained dental and possibly nondental personnel.
  27. 27. INDICES DRAKES – HANDICAPPING LABIOLINGUAL DEVIATION (HLD) INDEX 1. Cleft palate – All or none 2. Traumatic deviation – All or none 3. Overjet in mm 4. Over bite in mm 5. Mesiodistal protrusion in mm 6. Anterior open bite 7. Labiolingual spread in mm
  28. 28. California modification of Handicapping labiolingual deviation index To assess the presence or absence and degree of handicap caused by the components of the index and not to diagnose malocclusion. 1. Cleft palate deformities X - Score no further 2. Deep impinging overbite X - Score no further 3 Crossbite of individual anterior teeth X when soft tissue impingement 4 Severe traumatic deviation – loss of premaxilla – X 5 Overjet >9mm or ROJ >3.5 mm (mm)
  29. 29. 6 7 8 Overbite in mm Mandibular protrusion in mm x 5 Open bite in mm – No occlusal contact in anterior x 4 9 Ectopic eruption – Count each tooth x 3 (Except III molars) 10 Anterior crowding – Arch length def >3.5 Maxilla or mandible 5 points each 11 Labiolingual spread – Extent of deviation from the normal arch. 12 Posterior unilateral crossbite – 2/more teeth with minimum 1 molar.
  30. 30. Summary of the rules: (William S. Parker -1998 Aug) 1. Study models must be diagnostic. [This means that they must be properly poured and adequately trimmed with neither large voids nor positive bubbles present. Centric occlusion must be clearly indicated by pencil lines on the study models, making it possible to occlude the teeth on the models in centric occlusion. If study models are not diagnostic as described here, they are not accepted, and the provider receives a Resubmission Turnaround Document (RTD) and is asked to send new models that do fit these requirements. The RTD is sent only once. If the provider does not respond, the Treatment Authorization Request (TAR) is denied. If the new models are sent and are not diagnostic, the TAR is denied.]
  31. 31. 2. All measurements are judged on the basis of greater than or more than the minimal criteria considering only the erupted teeth seen on the study models. 3. Medi-Cal Eligibility Regulations for orthodontic services states: ”Only cases with permanent dentition will be considered.“ or ”If the patient is at least 13 years old, the index evaluation may be performed.“ 4. In cases with deep impinging bites soft tissue destruction should be visible on the study models. 5. Upper central incisors are to be used when measuring overjet, overbite (including reverse overbite), mandibular protrusion, and open bite.
  32. 32. 6. Ectopic eruption i. the eruption of the first molar resorption of distal root of the primary second molar ii. transposed teeth. iii. teeth in the maxillary sinus, iv. in the ascending ramus of the mandible v. when teeth develop in locations other than in the dental arches. vi. Ectopic teeth must be more than 50% blocked out and clearly out of the dental arch.
  33. 33. vii.Regarding mutually blocked out teeth, only one will be counted.     The most difficult issue is the use of the word ectopic its a better choice to eliminate ectopic as Draker did. Probably one could then drop the score cutoff to 25 points to adjust for this elimination. Still permitting the inclusion of some pretty ugly malocclusions that might otherwise not be approved. It does identify the worst malocclusions. Until someone satisfactorily defines handicapping malocclusions, the decision to identify the worst malocclusions as handicapping seems to be a satisfactory approach.
  34. 34. Demerits: Carlos and Ast tested the ability of the HLDI in distinguishing "handicapping" and "nonhandicapping" malocclusions. Clinical judgement made by orthodontists was used as the standard. The distributions of HLDI scores in the two groups were found to be largely overlapping, which indicated that the HLDI was unable to distinguish the so-called handicapping malocclusion. The HLD (CalMod) Index has proven to be a successful tool to identify a large range of very disfiguring malocclusions and two known destructive forms of malocclusion (deep destructive impinging bites and destructive individual anterior crossbites). These are all then certified as medically necessary handicapping malocclusions.
  35. 35.  MALOCCLUSION SEVERITY ESTIMATE – GRAINGER (1960-61) Measurements: 1) Overjet 2) Over bite 3) Anterior open bite 4) Congenitally missing maxillary incisors 5) First molar rotation 6) Posterior cross bite 7)Tooth displacement – actual and potential
  36. 36. Six malocclusion syndromes defined: i. Positive overjet, anterior open bite ii. Positive overjet, posterior over bite, distal molar relationship and posterior cross bite with maxillary teeth buccal to mesio distal teeth. iii. Negative overjet, mesial molar relationship, posterior cross bite iv. Tooth displacement v. Posterior open bite vi.Mesial molar, over jet, over bite, cross bite, midline diastema, midline deviation. vii.Mesial molar, mixed dentition analysis and actual tooth displacement.
  37. 37. Summer's Occlusal Index 1966. 1. 2. 3. 4. 5. 6. 7. 8. 9. Molar relation Overbite Overjet Posterior cross bite Posterior open bite Tooth displacement Midline relation Maxillary median diastema Congenitally missing maxillary incisors.
  38. 38. Seven Syndromes: 1. 2. 3. 4. 5. 6. 7. Overjet & open bite Distal molar relation, Overjet, Overbite, Posterior crossbite, Midline diastema and Midline deviation Congenitally missing maxillary incisors. Tooth displacement Posterior openbite Mesial molar relation, Mixed dentition analysis and tooth displacement Mesial molar relation, Overjet, Overbite, Posterior crossbite, Midline diastema and Midline deviation
  39. 39. TPI – GRAINGER 1967 (11 Weighted measurements) 1) Upper anterior segment overjet 2) Lower anterior segment overjet 3) Over bite 4) Anterior open bite 5) Congenitally missing incisors 6) Distal molar relation 7) Mesial molar relation 8) Posterior cross bite – maxillary teeth buccal to normal 9) Posterior cross bite – maxillary teeth lingual to normal 10) Tooth displacement 11) Gross anomalies
  40. 40. Seven malocclusion defined: 1) Maxillary expansion syndrome 2) Over bite 3) Retrognathism 4) Open bite 5) Prognathism 6) Maxillary collapse syndrome 7) Congenitally missing incisor.
  41. 41. Grainger described the index as a method of assessing the severity of the most common types of malocclusion, and hence, provided a means of ranking patients according to the severity of malocclusion, the degree of handicap, or their priority of treatment. The prerequisites for determining a handicap were defined by Grainger as follows: (1) unacceptable esthetics, (2) significant reduction in masticatory function, (3) traumatic condition predisposing to tissue destruction, (4) speech impairment, (5) unstable occlusion and (6) gross or traumatic defects.
  42. 42. Merits: A few manifestations of malocclusion, such as midline diastema and slight asymmetry, were rejected as being of little public health significance. Measurements could be made either clinically or indirectly from dental study casts.  In an attempt to revise the MSE, the TPI had corrected for scoring normalities as zero.  Inspection of the TPI form reveals that distal and mesial molar relations are considered equal.  The OI and the TPI were similar in many aspects because both were based on the MSE. Most of the measurements in the two indices were common, so were their definitions and methods of assessment.
  43. 43. Demerits:  It is inadequate for assessing the occlusion of the deciduous or mixed dentition.  As there is no "mixed dentition analysis" it is invalid to measure potential tooth displacement. 1. Popovich and Thompson compared the TPI and the subjective appraisal of orthodontists longitudinally at different age levels & the ratings of 0 to 2.5 - low 2.5 to 4.5 - middle > 4.5 - high 2. Ghafari et al. did a longitudinal evaluation of the TPI. They found that TPI was a valid epidemiologic indicator of malocclusion, but TPI values recorded in the transitional dentition do not predict the future severity of malocclusion in the permanent dentition.
  44. 44.  SALZMANN INDEX (1968)  Handicapping malocclusion assessment records 1. Intra arch deviation – missing teeth, crowding, spacing, rotation 2. Inter arch deviation – Overjet, overbite, cross bite, open bite, mesio distal 3. Handicappping dento facial deformities  i. Facial or oral clefts  ii. Lower lip palatal to maxillary incisors  iii. Occlusal interferences  iv. Functional jaw limitation  v. Facial asymmetrical  vi. Speech impairment
  45. 45.  Salzmann's purpose of developing the HMAR was to provide a means for establishing priority for treatment of handicapping malocclusion.  · Handicapping malocclusion and handicapping dentofacial deformity were defined as conditions that constitute a hazard to the maintenance of oral health and interfere with the well-being of the patient by adversely affecting dentofacial esthetics, mandibular function or speech.  A cut-off point was set at a score so that those patients whose scores were above the cut-off point would be treated by the professional personnel available in the community, at the same time keeping with the funds budgeted for orthodontics.  One important aspect of the HMAR is that it records and weighs functional problems, which no other index does.
  46. 46. A Peck and Peck index for assessing tooth shape deviations (1972 Apr AJO) Odontometry is the science of measuring the size and proportion of teeth. Harvey Peck and Sheldon Peck devised an index using which lower incisor crowding can be assessed from tooth size measurements obtained either from the mouth or from plaster casts. This spatial analysis of existing or potential malocclusions is an important diagnostic tool. Naturally well-aligned mandibular incisors possess are significantly smaller mesiodistally and larger faciolingually.
  47. 47. Mesiodistal width of mandibular incisor Index = ----------------------------------------------------- x 100 Faciolingual width of mandibular incisor MD/FL index is a numerical expression of the crown shape as viewed incisally. MD/FL index of well-aligned mandibular central incisors = 88.4 ± 4.3 lateral incisors = 90.4 ± 4.8. Clinical guidelines for the maximum limit of desirable MD/FL index values for the lower incisors: Mandibular central incisor 88-92 Mandibular lateral incisor 90-95
  48. 48. Applications: 1. Prediction of unerupted tooth size similar to mixeddentition analyses by Moyer's and Nance 2. Assessment of tooth size— arch size compatibility within the same arch. 3. Assessment of tooth size compatibility between the two arches - Bolton's ratio. This index has been well applied in studies of approximal and occlusal tooth wear. Reproximation ("stripping") is described as a clinical procedure for correcting tooth shape deviations.
  49. 49. WHO or FDI CLASSIFICATION – 1979: 1. Gross anomalies 2. Dentition – missing, supernumerary, malformed incisor, ectopic eruption 3. Space – Diastema, crowding, spacing 4. Occlusion – a) Incisal – maxillary mandibular overjet, cross bite, deep bite, open bite, midline shift. b) Lateral segment – AP relation, open bite, posterior cross bite.Subjective judgement of orthodontic treatment – Not necessary, doubtful, necessary, urgent. 
  50. 50. DENTAL AESTHETICS INDEX (DAI) Regression coefficient Scoring descriptions Actual weight Rounded wt 5.76 6 1. Number of missing visible teeth (incisor to premolar) 2. Assessment of anterior crowding 0 – No crowding 1 – One segment crowding 2 – Two segment crowding 3. Assessment of anterior spacing 0 – No crowding 1 – One segment crowding 2 – Two segment crowding 4. Midline diastema in mm 1.15 1 1.31 1 3.13 3 5. Largest anterior irregularity in maxilla (mm) 1.34 1 6. Largest anterior irregularity in mandible (mm) 1.34 1 7. Anterior maxilla overjet in mm 1.62 2 8. Anterior mandible overjet in mm 3.68 4 9. Anterior openbite in mm 3.69 4 10. Molar relation 0 – normal 1 – half cusp problem 2 – full cusp problem Total score 2.69 3 13.36 13
  51. 51. IOTN Dental health component Grade 1 – None – Variations < =1mm Grade 2 – Little 1) Overjet >3.5mm <6 mm with competent lips 2) Reverse overjet < =1mm 3) Overbite >3.5 mm with no gingival contour 4) Anterior or posterior cross bite <1 mm displacement between maximum intercuspation and retruded contact position. 5) Small anterior or lateral open bite >1mm <2mm 6) Mild displacement of teeth 1-2mm
  52. 52. Grade 3: Moderate 1) Overjet >3.5mm <6mm with incompetent lips 2) Reverse overjet >1mm <3.5mm 3) Increased overbite or complete overbite touching gingival, but without trauma 4) Cross bite 1-2mm 5) Moderate open bite >2mm <4mm 6) Moderate displacement 2-4mm
  53. 53. Grade 4: Great 1) Overjet 6-9mm 2) Reverse overjet >3.5mm with no functional difficulties 3) Overbite with gingival trauma 4) Crossbite >2mm 5) Posterior lingual cross bite (unilateral or bilateral) 6) Extreme anterior open bite >4mm 7) Displacement >4mm 8) Hypodontia or partial anodontia (1 missing tooth/quadrant)
  54. 54. Grade 5: Very great 1) Defects of cleft lip or palate 2 Overjet >9mm 3 Reverse overjet >3.5mm – mastication and speech difficulties 4 Impeded eruption of teeth because crowding, displacement, presence of supernumerary, retained deciduous teeth or pathology 5 Extensive hypodontia – requiring prerestorative orthodontics.
  55. 55. AESTHETIC COMPONENT OF IOTN I Children form: Orthodontic concern: 1. I am satisfied with the way my teeth come together 1- 4 2. I want to have my teeth straightened 4 – 1 Response options: Agree very much. Agree little. Disagree a little. Disagree very much.
  56. 56. Global negative Self-Evaluation scale (GSE) 1. At times I think I am no good at all 2. I feel I do not have much to be proud of 3. I certainly feel useless at times 4. All in all, I am inclined to feel that I am a failure 5. I have often wanted to be someone else. Response: 1. Doesnot apply at all 2. Does not apply well 3. Applies somewhat 4. Applies fairly well 5. Applies well 6. Applies exactly 1- 6
  57. 57. II Parents form: A. 1) I am satisfied with the way my child's teeth come together. 2) I want to have my child's teeth straightened B. It is equally important for boys and girls to have straight teeth C. The results of orthodontic treatment are good. Response: Agree – 1 Disagree – 2 Uncertain – 3 A review was presented at an AAO Consensus Conference on occlusal indices held in St. Louis in 1993.
  58. 58. Index of Orthodontic Treatment Need (IOTN) - W. C. Shaw AJO 1995 It ranks malocclusion in terms of the significance of various occlusal traits for the person's dental health and perceived esthetic impairment, with the intention of identifying those persons who would be benefited the most from orthodontic treatment. The Dental Health Component of IOTN. Each occlusal trait thought to contribute to the longevity and the satisfactory functioning of the dentition is defined and placed into five grades, with clear cut-off points between the grades. The index recognizes the most severe anomaly or dental diseases specific to that site. Summing scores for a series of individual traits is not performed. Thus, multiple minor variations, each of which is unimportant with respect to dental health, cannot be added together to place a person in a higher grade.
  59. 59. The Esthetic Component of IOTN. The esthetic component consists of a 10-point scale, illustrated by a series of numbered photographs from an earlier study, which were rated for attractiveness by laypersons and selected as being equidistantly spaced through the range of scores. A rating is allocated for overall dental attractiveness rather than specific morphologic similarity to the photographs. The value arrived at gives an indication of the patient's treatment need on the grounds of esthetic impairment, and by inference reflects the sociopsychologic need for orthodontic treatment. When applied in the clinical setting, the patient's lips are retracted with self-retaining lip retractors, and a rating allocated. The time taken to record both the dental health and esthetic components by an experienced examiner is approximately 1 minute. However, if several minor anomalies require examination to identify the most severe, grade allocation may take up to 3 minutes.
  60. 60. 1. Resource allocation and planning for limited public and other third-party resources for orthodontic care, to direct resources to cases most likely to derive benefit from treatment. 2. Monitoring and promoting standards. 3. Modification of the PAR Index there is also a place for an index of treatment complexity since this could be used for triage or allocation where groups of providers of varying levels of competence coexist. 4. Patient identification and referral. Access to orthodontic care is often determined by the general dentist or pedodontist. 5. Informed consent - The patient should also be provided with a candid description of the risks and stability of treatment, and thus be in a position to make a more balanced decision.
  61. 61. Disadvantage: Risk of insensitivity and misjudgment of the needs of the individual patient. None of the available systems can solve the dilemma of patients with minor irregularities about which they are deeply concerned and which may therefore have a bearing on self-esteem and self-confidence.
  62. 62. Peer Assessment Rating or PAR index Richmond 1987: 1) A scoring system was developed and a ruler designed to allow analysis of a set of study casts in approximately 2 minutes. 2) Individual scores for the components of alignment and occlusion are finally summed to calculate an overall score. Thus, a score of zero would indicate perfect alignment and occlusion and higher scores (rarely beyond 50) indicate increasing levels of irregularity. 3) The index is applied to both the start and the end of treatment study casts, and the change in the total score reflects the success of treatment in achieving overall alignment and occlusion.
  63. 63.  4 The PAR index and IOTN were applied to the pretreatment and posttreatment casts. The mean percentage reduction in PAR score was 52% and 21% of cases were unimproved or worse as a result of orthodontic treatment. When outcome was related to choice of appliance, combined upper and lower fixed appliances produced the best standard of treatment, mean reduction in PAR being 71%. Cases with a borderline need for treatment (IOTN grade 3) were more liable to have unsuccessful treatment. A lack of improvement or worsening of the malocclusion occurred in 34% of cases. the results obtained by spring type removable appliances were significantly inferior to those gained by fixed appliances.  5 Senior orthodontists with greater experience gained better results than trainees, and some centers provided a better overall standard of care than others, seemingly reflecting the differing aspirations of the heads of different centers
  64. 64. 6 7 The investigation of treatment standards is a more challenging step for the specialty. Poor standards of orthodontic care when nonspecialists provide treatment 8 Risk benefit balance was shown to be extremely uncertain for malocclusion with borderline need for treatment pointing to the high level of competence that would be required if moderate malocclusion is to be treated at all. 9 Indices of treatment outcome, however, can also be a powerful educational tool for the individual provider. For a provider's treatment standards to be acceptable, the percentage reduction in PAR score for a sample of cases should exceed a level agreed by consensus. the results obtained by spring type removable appliances were significantly inferior to those gained by fixed appliances.
  65. 65. 10. 1. 2. 3. 4. 5. The measurements made are: Overjet Overbite Midline relation Buccal Occlusion Upper anterior crowding
  66. 66. Ideal tooth relationship index - Haeger AJO May 1992 It is a static occlusal analysis in centric occlusion based on ideal interarch and intraarch relationships for quantitating the degree of interdigitation of the teeth. Applications 1) evaluating the results of orthodontic treatment 2) posttreatment stability, settling, relapse 3) different orthodontic treatment modalities and 4) assess treatment effects of orthodontic appliances
  67. 67.           Characteristic Features: Index scores were generated for the entire dentition, which could be divided into anterior, posterior, interarch, and intraarch relationships. Index scores were determined at various time intervals so the longitudinal changes could be studied. The number of potential ideal relationships varied depending on the number of teeth included, i.e., extraction cases and inclusion of second molars. No difference in scores if only first molars were included. The relationships were scored only when they were correct, and no range of "normal" was incorporated. If a buccal segment interdigitated mesially or distally to the Class I position, contacts were still counted as being present since functional inclined plane relationships were of primary interest. Models with congenitally missing teeth, questionable articulation, malformed teeth or broken or chipped teeth were not included in this study. Third molars were not included because of variability in form and occurrence. Deciduous teeth were excluded.
  68. 68. Results: Evaluation of treated malocclusions  Total ITRI score 1) An initial of 26% 2) Increased to 52% at the end of orthodontic treatment and 3) Continued to improve to 59% during the retention and post retention periods. 4) Anterior segment scores were higher (64%) than posterior segment scores (44%). 5) The intraarch relationships of the anterior segment registered the highest (75%), whereas the lingual cusp relationships of the posterior segment had the lowest scores (35%).
  69. 69.      Buccal relationships in the posterior segment produced higher scores than the lingual segment. Lingual cusp relations showed the smallest improvement as a result of orthodontic treatment but the largest amount of retention and post retention settling. Before treatment there were differences between the index scores of the various malocclusion groups. After orthodontic treatment, no difference in ITRI scores existed between the four malocclusion groups. This was true for both segments and all components. During the retention and postretention periods, the posterior intraarch scores of the Class II, Division 1 malocclusions increased an additional 15 percentage points.
  70. 70.  The system allowed the computation of a total index score that could be divided into arch segments and components of these segments so that details of occlusal changes during treatment and posttreatment could be followed.  Analysis of treatment results showed that anterior segments improved more than posterior segments, and buccal relations are handled better than lingual relations. It appears orthodontists do a better job correcting discrepancies that are more highly visible.  Occlusal relationships after orthodontic treatment were improved to approximately the same degree regardless of the type of malocclusion and, thereafter, showed similar settling and relapse.
  71. 71.  OCCULUSAL FEATURES INDEX BY POULTOND AARONSON – 1961 1. Lower anterior crowding 2. Cuspid interdigitation 3. Vertical over bite 4. Horizontal over jet.
  72. 72. FISK INDEX 1960: Dental age was used for grouping. A – P: Angle's classification, overjet, anterior crossbite Transverse: Posterior cross bite or scissor bite Vertical: Overbite/open bite (mm) Additional measurements: Labiolingual spread Spacing Therapeutic extractions Congenital or postnatal defects Mutilation Congenital absence Supernumerary teeth
  73. 73. BJORK, KREBS & SOLOW –1964 1. Dental anomalies, abnormal eruption, malalignment 2. Occlusal anomalies – Deviations between upper or lower arches in all 3 planes. 3. Space deviations: spacing and crowding. 
  74. 74.  1. 2. 3. 4. 5. PROFITT AND ACKERMANN – 1973 Alignment – Ideal, crowding, spacing, mutilated Profile – Mesiodistal prominence, mesiodistal recession, lip profile relative to nose and chin. (Convex, straight, concave) Posterior cross bite Saggital plane – Angle's classification Bite depth – Anterior or posterior open or deep bite
  75. 75.  EVALUATION OF MALOCCLUSION INDICES  The reproducibility or reliability of an index is the ability to produce the same score or measurement when one or more examiners measure the same case at the same or at a different time.  The validity of an index can be defined as its ability to accurately measure what it purports to measure.
  76. 76.  Bias, or systemic error of an index or measurement is the magnitude and direction of its tendency to measure something other than what was intended. The score of an unbiased index should accurately reflect the intended characteristics. For malocclusion indices, severity of malocclusion and the priority for treatment based on need would be the intended characteristics. An index could be precise but biased. In such a case, the score will be reproducible but not an accurate portrayal of the occlusion.
  77. 77.  Weights were first introduced to put different emphasis on various measurements.  Only the OI had developed different scoring schemes and scoring forms for patients in different stages of dental development, i.e, deciduous dentition, mixed dentition, and permanent dentition. Later, weighting systems were also included in the OI, the TPI, and the HMAR.
  78. 78.  Hermanson and Grewe tested the precision and bias of five malocclusion indices including the HMAR, the OI, the TPI, and two other indices. Their results showed that only the OI and the TPI demonstrated nonsignificant interexaminer variability at the 1% level, and that the most precise and unbiased index would be the OI or the TPI.
  79. 79.  Grewe and Hagan compared the HMAR, the OI, and the TPI for precision and bias when used in the same population. The results showed that all three indices were highly reproducible. When bias or systematic error was evaluated, the results indicated that the OI described the clinical standard most accurately. Therefore, of the three indices tested in the study, no one index can be selected over the others with regard to precision, but the OI would be the index of choice, with regard to having the least amount of bias.
  80. 80.  Summers tested the validity of three indices: The CHAMPUS index, the HMAR, and the OI. The OI was found to be the most valid among the three indices. When validity during time was tested, decreased scores were noted in the CHAMPUS index and the HMAR but not in the OI.
  81. 81.  Gray and Demirjian compared the reproducibility and accuracy of four indices: the HLDI, the TPI, the OI, and the HMAR. The results showed that all methods were highly reproducible but the OI had the best correlation with the clinical standard, which was determined by subjective assessment of orthodontists. The HLDI was found by Gray and Demirjian to identify only the very worst cases and tended to lump all the others into a common pool. Therefore it was unacceptable for overall field use.
  82. 82.  The TPI and the OI were very highly correlated and had some common characteristics. Both needed very close and careful examination as subjective decisions were required in deciding whether the molar relationship is distal or mesial by half a cusp or more than half a cusp on each side. A certain degree of subjective judgement was also involved in determining whether some teeth were rotated by 35° to 45° or more than 45°, and in determining displacement by 1.5 to 2 mm or more than 2 mm. Hence it required a well trained person to make accurate decisions because mistakes made would be serious due to the large differences in weighting factors influencing the decisions made. The OI, when compared with the TPI, was slightly more complicated to use and would require even more calculations and clerical time.
  83. 83. The HMAR correlates fairly well with the standard but not as closely as the TPI or the OI. However, it had advantages as well. Subjective decisions were not as critical as the TPI or the OI, because only full-cusp discrepancies were noted. If errors were made, they were not usually serious because the weighting system applied was only to the anterior segment and mostly for esthetics. Recording and calculation of the index was also simpler and required less time. In conclusion, The Summers occlusal index appear to have the least amount of bias has the highest validity during time and is best correlated with clinical standards.
  84. 84. Yet it still has short comings. Elderton and Clark pointed out that OI needs to be refined to allow scoring when first permanent molars are lost or drifted because difficulty and mistakes in measuring the malocclusion would arise in these situations. Tang and Wei used the OI to assess treatment effectiveness of orthodontic appliances and thought that the OI is not ideal because it does not take into account residual or extraction spaces, nor does it measure mesiodistal or buccolingual tooth inclinations. Further research would therefore be needed to develop better indices or to refine the present indices so that they can be more universally accepted.
  85. 85.   Conclusion: A good method of recording or measuring malocclusion is important for documentation of the prevalence and severity of malocclusion in population groups. This kind of data is not only important for the epidemiologist, but also for those who plan for the provision of orthodontic treatment in a community or for the training of orthodontic specialists. If the method is universally accepted and applied, data collected from different population groups can be compared.    Ø McLain and Proffit "occlusal problems cannot be defined solely in physical terms." They say that the psychosocial consequences due to unacceptable dental esthetics may be as serious, or even more serious, than the biologic problems.
  86. 86. Thank you For more details please visit www.indiandentalacademy.com

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